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Yes NoWas the accident report ffled with the insurance carrierT Yes NolJthe abovc has not been done, yw nedical exynsu will not k rccognizcdJu polncnt. Iour conpensotion benejB wi be d.ni.d and pqncnt *ould then baone your dirut rcpoDnbilit!.Are you working? Yes No Date last worked Regular job duties Yes NoLight job duties Yes No Date ReturnedDate Returned o CitY/State-zip Phone #-Contact Person- occure Workers Comp Insurance r ll--""Cirv/State zip-Phone #_----==-WCB Case #-CC#- State where and how injury lherebyarrthorize-tofumishinformationtoinsulancecarriersconcerning my illness and treatnents' and I hereby assign to the physician all paymens for medical services,"nd"."d io *yr.lf o. -y dependcnts. 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<54> Tj /F3 7.5 Tf 1 0 0 1 33.84 339.48 Tm <576F72746572732720> Tj /F3 7.0 Tf 1 0 0 1 65.88 339.84 Tm <436F6D70656E736174696F6E20> Tj 1 0 0 1 114.48 339.84 Tm <426F61726420> Tj 1 0 0 1 136.08 339.84 Tm <526567756C6174696F6E20> Tj /F3 8.0 Tf 1 0 0 1 174.24 340.20 Tm <333224312E323320> Tj /F3 7.0 Tf 1 0 0 1 205.92 340.92 Tm <7065726D69747320> Tj 1 0 0 1 232.56 340.92 Tm <796F757220> Tj 1 0 0 1 248.76 340.20 Tm <646F63746F7220> Tj 1 0 0 1 271.08 340.20 Tm <6F7220> Tj 1 0 0 1 279.72 340.20 Tm <74688072617069737420> Tj /F3 7.5 Tf 1 0 0 1 310.32 340.20 Tm <6C6F20> Tj /F3 7.0 Tf 1 0 0 1 318.96 340.20 Tm <7236717565737420> Tj /F3 7.5 Tf 1 0 0 1 345.60 340.20 Tm <7468736C20> Tj 1 0 0 1 360.00 340.92 Tm <796F7520> Tj /F3 7.0 Tf 1 0 0 1 374.76 340.20 Tm <7369676E20> Tj 1 0 0 1 390.24 340.20 Tm <7468697320> Tj 1 0 0 1 403.56 340.20 Tm <412D3920> Tj 1 0 0 1 417.60 339.84 Tm <6E6F746963802D20> Tj /F3 7.5 Tf 1 0 0 1 441.72 339.48 Tm <387920> Tj /F3 7.0 Tf 1 0 0 1 452.52 339.12 Tm <7369676E696E6720> Tj 1 0 0 1 477.72 339.12 Tm <74686973> Tj /F3 7.5 Tf 1 0 0 1 33.84 330.84 Tm <6E6F746963652C20> Tj /F3 7.0 Tf 1 0 0 1 58.68 331.56 Tm <796F7520> Tj 1 0 0 1 73.08 330.84 Tm <61636B6E6F776C6564676520> Tj 1 0 0 1 117.72 331.92 Tm <796F757220> Tj /F3 7.5 Tf 1 0 0 1 133.92 331.20 Tm <6F626C456174696F6E20> Tj /F3 8.0 Tf 1 0 0 1 168.48 331.20 Tm <746F20> Tj /F3 7.0 Tf 1 0 0 1 177.84 332.28 Tm <70617920> Tj /F3 7.5 Tf 1 0 0 1 192.24 331.56 Tm <74686520> Tj 1 0 0 1 205.20 332.28 Tm <70726F766964652F7320> Tj /F3 7.0 Tf 1 0 0 1 239.40 331.56 Tm <6665367320> Tj 1 0 0 1 255.60 331.56 Tm <666F7220> Tj /F3 7.5 Tf 1 0 0 1 266.40 331.56 Tm <74686520> Tj /F3 7.0 Tf 1 0 0 1 279.36 331.20 Tm <736F72766963657320> Tj /F3 7.5 Tf 1 0 0 1 308.52 331.92 Tm <796F7520> Tj /F3 7.0 Tf 1 0 0 1 323.28 331.56 Tm <726F636169766F20> Tj 1 0 0 1 349.56 331.56 Tm <696620> Tj /F3 7.5 Tf 1 0 0 1 355.68 331.56 Tm <696C20> Tj 1 0 0 1 361.80 331.56 Tm <74756D7320> Tj 1 0 0 1 380.52 331.20 Tm <6F756C20> Tj 1 0 0 1 393.48 331.56 Tm <7468616C20> Tj /F3 7.0 Tf 1 0 0 1 408.24 331.20 Tm <7375636820> Tj 1 0 0 1 426.24 331.20 Tm <6636657320> Tj /F3 7.5 Tf 1 0 0 1 442.44 330.84 Tm <61726520> Tj 1 0 0 1 455.76 330.84 Tm <6E6F6C20> Tj /F3 7.0 Tf 1 0 0 1 468.72 330.48 Tm <6C6567616C6C79> Tj 1 0 0 1 34.20 322.20 Tm <726571756972656420> Tj /F3 7.5 Tf 1 0 0 1 64.08 322.20 Tm <746F20> Tj /F3 7.0 Tf 1 0 0 1 73.08 322.20 Tm <628020> Tj 1 0 0 1 83.52 323.28 Tm <7061696420> Tj 1 0 0 1 99.72 322.20 Tm <627920> Tj 1 0 0 1 109.44 323.28 Tm <796F757220> Tj /F3 7.5 Tf 1 0 0 1 126.00 322.56 Tm <656D706C6F79657220> Tj 1 0 0 1 159.48 322.20 Tm <6F7220> Tj 1 0 0 1 168.84 322.56 Tm <696C7320> Tj /F3 8.0 Tf 1 0 0 1 178.56 322.56 Tm <776F726B65362720> Tj /F3 7.0 Tf 1 0 0 1 209.16 322.56 Tm <636F6D70806E736174696F6E20> Tj /F3 7.5 Tf 1 0 0 1 257.40 322.92 Tm <696E7375806E633620> Tj 1 0 0 1 291.60 322.56 Tm <63617264657220> Tj /F3 7.0 Tf 1 0 0 1 315.36 322.56 Tm <616E6420> Tj 1 0 0 1 330.12 322.92 Tm <696620> Tj 1 0 0 1 336.24 322.56 Tm <7375636820> Tj /F3 7.5 Tf 1 0 0 1 354.24 322.92 Tm <66656F7320> Tj 1 0 0 1 371.16 322.56 Tm <61726520> Tj /F3 7.0 Tf 1 0 0 1 384.48 322.56 Tm <6E6F7420> Tj 1 0 0 1 397.08 322.56 Tm <636F766F72656420> Tj 1 0 0 1 425.88 322.20 Tm <627920> Tj /F3 7.5 Tf 1 0 0 1 435.96 321.84 Tm <6F6C68657220> Tj /F3 7.0 Tf 1 0 0 1 455.40 321.84 Tm <696E737572616E63652E> Tj 1 0 0 1 33.84 313.20 Tm <54686520> Tj /F3 7.5 Tf 1 0 0 1 48.96 313.20 Tm <656D706C6F7965726F7220> Tj /F3 8.0 Tf 1 0 0 1 90.00 313.56 Tm <63617269657220> Tj /F3 7.0 Tf 1 0 0 1 112.68 313.56 Tm <6D617920> Tj 1 0 0 1 128.52 313.92 Tm <6E6F7420> Tj /F3 7.5 Tf 1 0 0 1 140.76 313.56 Tm <626520> Tj 1 0 0 1 151.56 313.92 Tm <72652B726B656420> Tj 1 0 0 1 180.72 313.92 Tm <746F20> Tj /F3 7.0 Tf 1 0 0 1 189.72 314.64 Tm <70617920> Tj 1 0 0 1 203.76 313.92 Tm <74686520> Tj /F3 7.5 Tf 1 0 0 1 216.00 313.92 Tm <646F636C6F2F7320> Tj /F3 7.0 Tf 1 0 0 1 243.72 313.92 Tm <6665657320> Tj /F3 6.5 Tf 1 0 0 1 259.56 313.92 Tm <69662C20> Tj /F3 7.0 Tf 1 0 0 1 267.12 313.92 Tm <666F7220> Tj 1 0 0 1 277.92 313.92 Tm <6578616D706C802E20> Tj 1 0 0 1 310.32 314.64 Tm <796F7520> Tj /F3 8.0 Tf 1 0 0 1 324.00 313.92 Tm <6661696C746F20> Tj /F3 7.0 Tf 1 0 0 1 343.80 313.92 Tm <6C6C6C8020> Tj 1 0 0 1 355.32 313.92 Tm <6120> Tj 1 0 0 1 361.80 313.92 Tm <636C61696D20> Tj 1 0 0 1 381.24 313.92 Tm <666F7220> Tj 1 0 0 1 392.04 313.92 Tm <7767726B6572732720> Tj /F3 6.5 Tf 1 0 0 1 421.20 313.20 Tm <636F6D70656E736174616F6E2C20> Tj /F3 8.0 Tf 1 0 0 1 470.88 312.84 Tm <6F726661696C> Tj /F3 7.0 Tf 1 0 0 1 33.84 304.56 Tm <746F20> Tj /F3 9.0 Tf 1 0 0 1 42.48 304.56 Tm <6E6F74697420> Tj /F3 7.0 Tf 1 0 0 1 63.36 305.28 Tm <796F757220> Tj 1 0 0 1 79.92 304.56 Tm <656D706C6F79657220> Tj 1 0 0 1 111.60 304.92 Tm <6F6620> Tj 1 0 0 1 120.24 305.64 Tm <796F757220> Tj 1 0 0 1 137.16 304.92 Tm <696E6A75727920> Tj /F3 8.0 Tf 1 0 0 1 157.32 304.92 Tm <6F7220> Tj /F3 7.0 Tf 1 0 0 1 167.04 304.92 Tm <696C6C6E6573732C20> Tj 1 0 0 1 192.24 304.92 Tm <6F7220> Tj 1 0 0 1 201.24 304.92 Tm <6661696C20> Tj /F3 7.5 Tf 1 0 0 1 213.12 304.92 Tm <746F20> Tj 1 0 0 1 222.12 304.92 Tm <617469656E6420> Tj /F3 7.0 Tf 1 0 0 1 245.16 304.92 Tm <6120> Tj 1 0 0 1 251.64 304.92 Tm <426F61726420> Tj 1 0 0 1 273.24 304.92 Tm <68656172696E6720> Tj /F3 6.5 Tf 1 0 0 1 300.60 305.28 Tm <696620> Tj /F3 7.0 Tf 1 0 0 1 306.36 305.64 Tm <796F757220> Tj 1 0 0 1 323.28 304.92 Tm <656D706C6F79657220> Tj 1 0 0 1 356.04 304.92 Tm <6368616C6C656E67657320> Tj 1 0 0 1 394.20 305.64 Tm <796F757220> Tj /F3 8.5 Tf 1 0 0 1 411.12 304.92 Tm <6967687420> Tj /F3 7.0 Tf 1 0 0 1 427.68 304.56 Tm <746F20> Tj 1 0 0 1 436.32 304.56 Tm <62656E65666974732E20> Tj 1 0 0 1 466.56 303.84 Tm <4576656E20> Tj /F3 7.5 Tf 1 0 0 1 485.28 303.84 Tm <6966> Tj 1 0 0 1 33.84 296.28 Tm <796F7520> Tj /F3 7.0 Tf 1 0 0 1 48.96 295.92 Tm <6D616B6520> Tj /F3 8.5 Tf 1 0 0 1 69.48 295.92 Tm <646C20> Tj /F3 7.0 Tf 1 0 0 1 79.20 295.92 Tm <726571756972656420> Tj 1 0 0 1 107.64 295.92 Tm <6566696F647320> Tj /F3 8.0 Tf 1 0 0 1 129.96 295.92 Tm <6C6F20> Tj /F3 7.0 Tf 1 0 0 1 138.96 297.00 Tm <70726F73806375746520> Tj 1 0 0 1 174.24 296.64 Tm <796F757220> Tj 1 0 0 1 191.16 296.28 Tm <636C61696D2C20> Tj 1 0 0 1 213.12 296.28 Tm <74686520> Tj /F3 7.5 Tf 1 0 0 1 225.72 296.28 Tm <576F66746572732720> Tj /F3 7.0 Tf 1 0 0 1 256.68 296.28 Tm <436F6D70806E736174696F6E20> Tj 1 0 0 1 306.72 296.28 Tm <426F61726420> Tj 1 0 0 1 328.68 296.28 Tm <6D617920> Tj /F3 7.5 Tf 1 0 0 1 344.88 295.92 Tm <736C696C6C20> Tj 1 0 0 1 357.84 296.28 Tm <74696E6420> Tj /F3 7.0 Tf 1 0 0 1 372.60 296.28 Tm <7468617420> Tj 1 0 0 1 387.36 297.00 Tm <796F7520> Tj 1 0 0 1 401.76 295.92 Tm <61726520> Tj /F3 7.5 Tf 1 0 0 1 414.72 295.92 Tm <6E6F6C20> Tj /F3 7.0 Tf 1 0 0 1 427.32 295.56 Tm <656E7469746C656420> Tj 1 0 0 1 452.88 295.20 Tm <746F20> Tj 1 0 0 1 461.52 295.20 Tm <62656E65666974732E> Tj 1 0 0 1 34.20 286.92 Tm <6C6E20> Tj /F3 7.5 Tf 1 0 0 1 42.12 286.92 Tm <7375636820> Tj /F3 7.0 Tf 1 0 0 1 60.48 286.92 Tm <63617365732C20> Tj 1 0 0 1 83.52 287.28 Tm <7468697320> Tj 1 0 0 1 96.84 287.28 Tm <6E6F7469636520> Tj 1 0 0 1 118.08 287.28 Tm <6164766973657320> Tj 1 0 0 1 145.08 288.00 Tm <796F757220> Tj 1 0 0 1 162.00 287.28 Tm <6865616C746820> Tj 1 0 0 1 184.68 288.00 Tm <70726F766964657220> Tj 1 0 0 1 213.12 287.28 Tm <7468617420> Tj 1 0 0 1 227.88 288.00 Tm <796F7520> Tj 1 0 0 1 241.92 287.28 Tm <61636B6E6F776C3664673620> Tj 1 0 0 1 286.20 288.00 Tm <796F757220> Tj 1 0 0 1 303.12 288.00 Tm <706F72736F6E616C20> Tj 1 0 0 1 333.00 287.28 Tm <6C696162696C69747920> Tj /F3 7.5 Tf 1 0 0 1 357.12 287.28 Tm <666F7220> Tj /F3 7.0 Tf 1 0 0 1 368.64 288.00 Tm <7061796D656E7420> Tj /F3 7.5 Tf 1 0 0 1 398.52 287.28 Tm <6F6C20> Tj /F3 7.0 Tf 1 0 0 1 406.80 287.28 Tm <6869732F68367220> Tj 1 0 0 1 430.92 286.56 Tm <62696C6C732E> Tj 0.00 Tc /F3 8.0 Tf 1 0 0 1 33.84 268.20 Tm <576F2E6B6572732720> Tj /F3 7.5 Tf 1 0 0 1 68.04 268.20 Tm <436F6D70656E736174696F6E20> Tj 1 0 0 1 120.24 268.56 Tm <4C617720> Tj 1 0 0 1 136.44 268.56 Tm <536563746C6F6E20> Tj /F3 7.0 Tf 1 0 0 1 165.60 268.56 Tm <3332> Tj 1 0 0 1 33.84 259.56 Tm <54686520> Tj /F3 7.5 Tf 1 0 0 1 48.96 259.56 Tm <412D3920> Tj /F3 7.0 Tf 1 0 0 1 63.36 259.92 Tm <6E6F6C69636520> Tj /F3 6.5 Tf 1 0 0 1 84.60 259.56 Tm <616C736F20> Tj /F3 7.0 Tf 1 0 0 1 99.72 259.92 Tm <636F7665727320> Tj 1 0 0 1 123.12 259.92 Tm <696E7374616E63657320> Tj /F3 6.0 Tf 1 0 0 1 156.96 259.92 Tm <696E20> Tj /F3 7.0 Tf 1 0 0 1 164.16 259.92 Tm <776869636820> Tj 1 0 0 1 185.76 259.92 Tm <6120> Tj 1 0 0 1 192.24 259.92 Tm <636C61696D616E7420> Tj 1 0 0 1 221.76 259.92 Tm <7769746820> Tj /F3 6.5 Tf 1 0 0 1 237.24 259.92 Tm <616E20> Tj /F3 7.0 Tf 1 0 0 1 247.32 259.92 Tm <657869736C696E6720> Tj 1 0 0 1 273.60 259.92 Tm <76616C696420> Tj 1 0 0 1 290.88 259.92 Tm <776F726B6572732720> Tj 1 0 0 1 320.76 259.92 Tm <636F6D70656E73616C696F6E20> Tj 1 0 0 1 368.64 259.92 Tm <6361736520> Tj 1 0 0 1 386.28 259.92 Tm <636F6D657320> Tj 1 0 0 1 409.68 259.92 Tm <746F20> Tj /F3 6.5 Tf 1 0 0 1 418.32 259.56 Tm <616E20> Tj /F3 7.0 Tf 1 0 0 1 428.40 259.20 Tm <61677265656D656E7420> Tj 1 0 0 1 465.12 258.84 Tm <77697468> Tj 1 0 0 1 34.20 250.92 Tm <6869732F68657220> Tj 1 0 0 1 58.68 250.56 Tm <656D706C6F79657220> Tj 1 0 0 1 90.72 250.92 Tm <6F7220> Tj /F3 6.0 Tf 1 0 0 1 99.36 251.28 Tm <726C7320> Tj /F3 7.0 Tf 1 0 0 1 108.36 250.92 Tm <696E73756C616E638020> Tj /F3 7.5 Tf 1 0 0 1 142.20 250.92 Tm <63616E69807220> Tj /F3 8.0 Tf 1 0 0 1 165.60 250.92 Tm <73657474696E6720> Tj /F3 7.0 Tf 1 0 0 1 191.88 251.28 Tm <6869732F68657220> Tj /F3 7.5 Tf 1 0 0 1 216.00 251.28 Tm <6361736520> Tj /F3 6.0 Tf 1 0 0 1 234.36 251.28 Tm <696E20> Tj /F3 7.0 Tf 1 0 0 1 241.56 250.92 Tm <6163636F7264616E636520> Tj 1 0 0 1 281.16 251.28 Tm <7769746820> Tj 1 0 0 1 296.64 250.92 Tm <53656374696F6E20> Tj /F3 6.5 Tf 1 0 0 1 323.28 250.92 Tm <333220> Tj /F3 7.5 Tf 1 0 0 1 333.36 250.92 Tm <6F6674686520> Tj /F3 7.0 Tf 1 0 0 1 353.52 251.28 Tm <576F726B6F72732720> Tj 1 0 0 1 385.20 250.92 Tm <436F6D70656E736174696F6E20> Tj /F3 6.5 Tf 1 0 0 1 434.52 250.56 Tm <4C61772E20> Tj /F3 7.0 Tf 1 0 0 1 451.44 250.20 Tm <4120> Tj 1 0 0 1 458.64 250.20 Tm <53656374696F6E> Tj /F3 6.5 Tf 1 0 0 1 34.20 241.92 Tm <333220> Tj /F3 7.5 Tf 1 0 0 1 44.28 241.92 Tm <61677265656674656E7420> Tj /F3 6.5 Tf 1 0 0 1 82.08 242.28 Tm <6D617920> Tj /F3 7.0 Tf 1 0 0 1 97.56 242.28 Tm <696E636C75646F20> Tj /F3 6.5 Tf 1 0 0 1 122.76 241.92 Tm <6120> Tj /F3 7.0 Tf 1 0 0 1 128.88 243.00 Tm <70726F766973696F6E20> Tj 1 0 0 1 160.56 242.28 Tm <776869636820> Tj 1 0 0 1 182.16 242.28 Tm <72656C696576657320> Tj 1 0 0 1 209.88 242.28 Tm <74686520> Tj 1 0 0 1 222.48 242.28 Tm <656D706C6F79657220> Tj /F3 6.5 Tf 1 0 0 1 254.52 242.28 Tm <6F7220> Tj /F3 7.0 Tf 1 0 0 1 262.80 242.28 Tm <6361727269657220> Tj 1 0 0 1 285.84 242.28 Tm <6F6620> Tj 1 0 0 1 294.12 242.28 Tm <74686520> Tj 1 0 0 1 306.72 242.28 Tm <6C696162696C69747920> Tj 1 0 0 1 330.48 242.28 Tm <746F20> Tj 1 0 0 1 339.12 243.00 Tm <70617920> Tj 1 0 0 1 352.80 242.28 Tm <66757475726520> Tj 1 0 0 1 374.40 242.28 Tm <6D65646963616C20> Tj 1 0 0 1 401.76 242.28 Tm <62696C6C7320> Tj 1 0 0 1 416.16 241.92 Tm <6173736F6369616C656420> Tj 1 0 0 1 452.88 241.56 Tm <7769746820> Tj 1 0 0 1 468.00 241.20 Tm <746865> Tj /F3 7.5 Tf 1 0 0 1 33.84 232.92 Tm <636173652E20> Tj /F3 7.0 Tf 1 0 0 1 54.36 233.28 Tm <596F757220> Tj /F3 6.5 Tf 1 0 0 1 72.36 233.28 Tm <6865616C746820> Tj /F3 7.0 Tf 1 0 0 1 93.60 233.28 Tm <6361726520> Tj 1 0 0 1 109.80 234.00 Tm <70726F766964657220> Tj 1 0 0 1 138.24 233.28 Tm <6D617920> Tj 1 0 0 1 154.80 233.28 Tm <61736B20> Tj 1 0 0 1 168.48 234.00 Tm <796F7520> Tj 1 0 0 1 182.52 233.64 Tm <746F20> Tj 1 0 0 1 191.16 233.28 Tm <7369676E20> Tj 1 0 0 1 206.64 233.64 Tm <7468697320> Tj /F3 7.5 Tf 1 0 0 1 219.96 233.64 Tm <412D3920> Tj /F3 6.5 Tf 1 0 0 1 234.36 233.64 Tm <6E6F7469636520> Tj /F3 7.5 Tf 1 0 0 1 255.24 233.64 Tm <6C6F20> Tj /F3 7.0 Tf 1 0 0 1 263.52 233.64 Tm <696E7375726520> Tj 1 0 0 1 285.48 233.64 Tm <7468617420> Tj 1 0 0 1 300.24 234.00 Tm <796F7520> Tj 1 0 0 1 313.92 233.28 Tm <61636B6E6F776C6564678020> Tj 1 0 0 1 358.92 234.00 Tm <796F757220> Tj 1 0 0 1 375.84 234.36 Tm <706572736F6E616C20> Tj 1 0 0 1 406.08 233.28 Tm <6C696162696C69747920> Tj 1 0 0 1 429.84 232.92 Tm <666F7220> Tj 1 0 0 1 440.64 233.64 Tm <7061796D656E7420> Tj /F3 7.5 Tf 1 0 0 1 470.52 232.56 Tm <6F66> Tj /F3 7.0 Tf 1 0 0 1 34.20 224.28 Tm <6869732F68657220> Tj 1 0 0 1 59.04 224.28 Tm <62696C6C7320> Tj /F3 6.0 Tf 1 0 0 1 73.80 224.28 Tm <696620> Tj /F3 7.0 Tf 1 0 0 1 79.20 225.00 Tm <796F7520> Tj /F3 6.5 Tf 1 0 0 1 92.88 224.28 Tm <6861763620> Tj /F3 7.0 Tf 1 0 0 1 110.16 224.28 Tm <77616976656420> Tj 1 0 0 1 135.36 225.00 Tm <796F757220> Tj 1 0 0 1 152.28 224.64 Tm <726967687420> Tj 1 0 0 1 168.84 224.64 Tm <746F20> Tj 1 0 0 1 177.12 224.64 Tm <66757475726520> Tj 1 0 0 1 198.72 224.64 Tm <6D65646963616C20> Tj 1 0 0 1 226.44 224.64 Tm <62656E656669747320> Tj /F3 6.5 Tf 1 0 0 1 254.16 224.64 Tm <756E64657220> Tj /F3 7.0 Tf 1 0 0 1 274.32 224.64 Tm <6120> Tj 1 0 0 1 280.80 224.64 Tm <53656374696F6E20> Tj /F3 6.5 Tf 1 0 0 1 307.80 224.64 Tm <333220> Tj /F3 7.0 Tf 1 0 0 1 317.88 224.64 Tm <61677265806D806E6C2E> Tj 0.00 Tc /F3 7.5 Tf 1 0 0 1 34.56 205.92 Tm <6C6620> Tj /F3 8.0 Tf 1 0 0 1 41.04 206.28 Tm <796F7520> Tj /F3 7.5 Tf 1 0 0 1 56.88 205.92 Tm <6861766520> Tj 1 0 0 1 75.96 205.92 Tm <616E7920> Tj /F3 7.0 Tf 1 0 0 1 90.72 206.64 Tm <717565736C696F6E732C20> Tj /F3 7.5 Tf 1 0 0 1 126.72 206.28 Tm <636F6E7461637420> Tj 1 0 0 1 154.08 207.00 Tm <796F757220> Tj 1 0 0 1 172.08 206.28 Tm <6174746F6D657920> Tj /F3 8.0 Tf 1 0 0 1 202.32 206.28 Tm <6F7220> Tj /F3 7.5 Tf 1 0 0 1 212.04 206.28 Tm <6C6963656E73656420> Tj /F3 7.0 Tf 1 0 0 1 242.64 206.28 Tm <68656172696E6720> Tj /F3 7.5 Tf 1 0 0 1 269.64 206.28 Tm <726570726573656E7461746976652E20> Tj 1 0 0 1 321.84 206.28 Tm <696620> Tj 1 0 0 1 328.32 207.00 Tm <796F7520> Tj 1 0 0 1 343.44 206.64 Tm <6861766520> Tj 1 0 0 1 362.52 206.28 Tm <6F6E652E20> Tj 1 0 0 1 380.52 206.28 Tm <596F7520> Tj /F3 7.0 Tf 1 0 0 1 396.72 206.28 Tm <6D617920> Tj /F3 7.5 Tf 1 0 0 1 413.28 205.92 Tm <616C736F20> Tj /F3 7.0 Tf 1 0 0 1 429.84 205.92 Tm <636F6E7461637420> Tj /F3 7.5 Tf 1 0 0 1 456.12 206.28 Tm <796F757220> Tj /F3 7.0 Tf 1 0 0 1 473.76 205.56 Tm <6C6F63616C> Tj 1 0 0 1 34.20 196.92 Tm <646973747269637420> Tj 1 0 0 1 57.96 196.92 Tm <6F666969636520> Tj 1 0 0 1 77.76 197.28 Tm <6F6620> Tj /F3 6.5 Tf 1 0 0 1 86.04 197.28 Tm <74686520> Tj /F3 7.0 Tf 1 0 0 1 97.56 197.28 Tm <576F726B6572732720> Tj 1 0 0 1 128.52 197.28 Tm <436F6D70656E736174696F6E20> Tj 1 0 0 1 178.92 197.28 Tm <426F6172642E> Tj 0.00 Tc /F3 7.5 Tf 1 0 0 1 33.84 183.24 Tm <544F20> Tj 1 0 0 1 46.80 183.60 Tm <54484520> Tj /F3 7.0 Tf 1 0 0 1 64.80 183.24 Tm <4845414C544820> Tj 1 0 0 1 95.76 183.60 Tm <4341524520> Tj /F3 7.5 Tf 1 0 0 1 118.44 183.60 Tm <50524F5649444552> Tj 1 0 0 1 34.20 173.88 Tm <5468697320> Tj /F3 7.0 Tf 1 0 0 1 51.12 174.24 Tm <6E6F7469636520> Tj 1 0 0 1 73.44 174.24 Tm 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(lr Knowh) NATURE OF INJURY ORILLNESS INJUREo PERSoiI_soc sEc. No NAME AOORESS iFirO INSURANCE You may become responsible for the medical costs of treatment for your illness or condition with theprovider listed below if (1) you fail to prosecuta the claim for workers' compensation or (2) itisdetermined by the Workers' Compensation Board that the illness or condition which required treatmentwas not a result of a compensable workplace accident or occupational disease or (3) if an agreement isexecuted by you and approved pursuant to Workers' Compensation Law S32 in which you waive yourright to medical benefits from the workers' compensation canier/sslf-insured employr for treatmenuservices performed after the date the agreement is approved. lf any of the above events occurs, theprovider may bill you directly instead of the employer or insurance canier, and you will be responsiblefor the providefs fees for services rendered.I hereby acknowledge that I have read the above and understand the circumstances under which I maybecome responsible for payment. Claimants Signature_ _ Date Provider's Name and Address IO THE CLAI A TWorters' Compensation Board Regulation 32$1.23 permits your doctor or thrapist lo r6quest thsl you sign this A-9 notic- 8y signing thisnotice, you acknowledge your oblEation to pay the provide/s fe6s for the sorvices you rocaivo if il tums oul thal such f6es are nol legallyrequired to b paid by your employer or ils worke6' compnsation insunc6 carder and if such feos are not covored by olher insurance.The employeror carier may not be re+rked to pay the doclo/s fees if, for exampl. you failto lll a claim for wgrkers' compensataon, orfailto notit your employer of your injury or illness, or fail to atiend a Board hearing if your employer challenges your ight to benefits. Even ifyou make dl required efiods lo proscute your claim, the Wofters' Compnsation Board may slill tind that you are nol entitled to benefits.ln such cases, this notice advises your health provider that you acknowl6dg6 your porsonal liability for payment ol his/h6r bills. Wo.kers' Compensation Law Sectlon 32The A-9 nolice also covers instances in which a claimant with an exisling valid workers' compensalion case comes to an agreement withhis/her employer or rls insulanc canir setting his/her case in accordance with Section 32 ofthe Workors' Compensation Law. A Section32 agreeftent may includo a provision which relieves the employer or carrier of the liability to pay future medical bills associaled with thecase. Your health care provider may ask you to sign this A-9 notice lo insure that you acknowledg your personal liability for payment ofhis/her bills if you hav6 waived your right to future medical benefits under a Section 32 agremnl. lf you have any queslions, contact your attomey or licensed hearing representative. if you have one. You may also contact your localdistrict ofiice of the Workers' Compensation Board. TO THE HEALTH CARE PROVIDERThis notice is meant to advise the wo*ers' compensation claimant that he/she may be rsponsible for payment. Failure ol th claimant tosign this form does nol relieve the provider of the obligation lo trat the claimant, nor dos it nogatg th claimants responsibility forpayment.Keep the odginal of this form for your records and give a copy to the claimant. Do nol llla wlth the WorkaB' Companletlon Board. Youv/ill receive Notices of Decisions in which the compensabiiity of a claim, authorizalion of Leatmsnt, or payment of modical bills is included.You will also be notified if the claimant submils a Section 32 Agroment with th6 Board fo. approval. Do not bill the claimant unless anduntjl you receive a Board decision finding that 1) claimant failed to prosecule lhe claim, or 2) the claim is denied, or 3) the lreatment is notcausally rolated to lhe work injury, or 4) a Soction 32 agrooment relioving th carior of liability for mdical lreatmont is approved. 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